TheraPets Facility Request

This form is reserved for those facilities interested in hosting recurring visits and becoming a TheraPets Partner. To request TheraPets for a one-time visit or special event, please fill out this form.

Facility Information

Facility Name *

Is this a non-profit facility/organization? *

• Yes
• No
• Not Applicable

Address *

City, State, Zip *

Facility Type (check all that apply) *

• Hospital
• Children's Hospital
• Veterans Hospital/Care Facility
• Psychiatric Hospital
• Residential Treatment Facility
• Assisted Living Facility
• Independent Senior Living
• Nursing Home/Long-Term Care
• Memory Care Facility
• Hospice Care
• Homeless Shelter
• Domestic Violence Shelter
• Library
• Special Education Classroom
• Pre-School/Daycare
• Elementary School
• Middle School
• High School
• Adult/Senior Day Center
• Teen Diversion Program
• Support Group
• Other (please specify)

If you selected "Other", please specify: *

Contact Person

Name *

Title *

Phone *

Email *

Visit Information

Days Available for Visits *

• Monday
• Tuesday
• Wednesday
• Thursday
• Friday
• Saturday
• Sunday
• ANYday

Time of Day *

• Morning, 9-11 a.m.
• Early Afternoon, 12-3 p.m.
• Late Afternoon, 3-5 p.m.
• Evening 5-7 p.m.
• ANYtime

Ideally, how often would you like visits? Check all that apply (choice does not guarantee availability) *

• Monthly
• Semimonthly
• Weekly
• Semiweekly
• Whenever Available
• We're Flexible!

Describe area where visits will take place (centralized location, individual rooms, etc.) *

Preferred Species of Visiting TheraPet *

• Dogs
• Cats
• Rabbit/Guinea Pig
• Bird
• ANY Animal

Description of Clients *

• Elderly
• Memory Impaired
• Fragile Health
• Traumatic Brain Injury
• Physical Disabilities
• Anxiety Disorders
• Mental Health Conditions
• Developmental Disabilities
• Intellectual Disabilities
• Children (toddler-kindergarten)
• Children (grades K-2)
• Children (grades 3-5)
• Children (middle school)
• Children (high school)
• Adults
• Other (please explain)

If you selected "Other", please specify: *

How many people (on average) would you expect to participate in our visits? *

Are there any pets residing in your facility? (facility cat/dog, pets owned by residents, etc.) If yes, what species/how many/where are they located? *

Do you receive other pet visits? If yes, by whom and how often? *

Please describe your requirements for new volunteers (orientation, background checks, health exam, etc.) *

Please share any other information about your facility that you would deem helpful to us and our volunteers (parking, building entry, etc.) *

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While we strive to respond to every visit request and do so in a timely manner, the continued increased demand for our program's services has, at times, made this goal difficult to achieve. 
Please keep this in mind when submitting your request.